April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Zhang et al

mostly those who were adopted internationally. Previously, Sullivan et al. (2014) found that later age of palatoplasty in internationally adopted children was associated with disor- dered speech. In this study, there was an association of older age of primary CL repair and more severe nasal obstructive symptoms. As most of the subjects with later CL repair were adopted internationally, potentially these children may develop worse deformity and dysfunction that only become apparent in adolescence. This may be due to differences in timing, tech- nique, or management. These findings suggest the potential benefit of cleft programs working with families and adoption agencies to promote earlier CL repairs and continued interna- tional collaboration to promote best practices in repair techniques. Additional points of debate with regard to primary CL repair include the role and benefits of preoperative NAM, postopera- tive nasal splints, and primary tip rhinoplasty. Some evidence suggests that NAM achieves improved nasal symmetry that is stable through early childhood (Maull et al., 1999; Barillas et al., 2009; Uzel and Alparslan, 2011; Abbott and Meara, 2012). However, the procedure can cause irritation of the oral mucosal or gingival tissue (Grayson and Maull, 2004) and there is a paucity of high-level evidence evaluating the effectiveness of NAM (Uzel and Alparslan, 2011; Abbott and Meara, 2012). This study’s finding that there was no difference in NOSE scores between the NAM cohort and age-matched non-NAM cohort suggests that although the procedure may initially achieve greater nasal symmetry, subjects may still be prone to develop nasal obstruction due to septal deviation or altera- tions in the external nasal valve. As the NAM cohort is still young, the authors will need to continue to follow subjects and see whether differences emerge during late childhood. The authors also acknowledge that subjects who undergo NAM may present with more severe phenotypes. Nasoalveolar mold- ing may have the benefit of facilitating easier primary lip repair (Yang et al., 2003; Radhakrishnan et al., 2010), even if no differences in functional outcomes are observed. The use of nasal splints postoperatively has been shown to preserve nasal symmetry and improve long-term aesthetic results, although the use of the splint for at least 6 months postoperatively was needed (Yeow et al., 1999). The results of this study show that this potentially improved nasal symme- try is not associated with a lower likelihood of nasal obstruc- tion. However, subjects at the authors’ institution typically only used nasal splints for 1 to 2 months postoperatively. Additional prospective studies utilizing the NOSE survey may serve to correlate the length of treatment with nasal splints with func- tional benefits. Proponents of primary tip rhinoplasty have provided evi- dence that the intervention improves nasal tip symmetry with- out disrupting growth centers (McComb and Coghlan, 1996; Millard and Morovic, 1998; Salyer et al., 2003), may reduce need for subsequent rhinoplasty operations (Gudis and Patel, 2014), and allows less complex operation at the time of defi- nitive secondary cleft rhinoplasty (Haddock et al., 2012). How- ever, asymmetric healing and scar tissue can lead to

Figure 3. Bar chart comparing the severity of nasal blockage with regard to Veau classification, based on group aggregate NOSE survey responses.

of the isolated CL patients had alveolar clefts. The cohort of isolated CL in the study by Sobol et al may have had a greater proportion of subjects with no alveolar involvement. In addi- tion, the small number of patients with isolated CL with alveo- lus in this study may preclude a meaningful statistical analysis. Although subjects older than 14 years of age reported the most severe symptoms in this study, another age peak of severe nasal obstructive symptoms was seen in children aged younger than 5. Nasal congestion was the most problematic symptom. Although the survey cannot discriminate between acute and chronic cases of nasal congestion, the common reporting of nasal obstruction by either parent proxies or patients indicates the importance of increased clinician awareness, as well as collaboration with primary care and otolaryngology specialists to medically manage congestive symptoms. There are addi- tional structural causes such as enlarged tonsils or adenoids which may contribute to nasal obstruction, and cleft nasal deformity is another potential contributor to consider as patients continue to grow and develop. The higher prevalence and more severe symptoms among subjects with CL deformity compared to those with only CP suggest the importance of evaluating the long-term functional, in addition to aesthetic, implications of different approaches to primary CL repair. The optimal time for CL repair is generally considered to be between 2 and 6 months (Lewin, 1964; Wil- helmsen and Musgrave, 1967; Farmand, 2002), although some studies have recommended earlier repair (Bromley et al., 1983;Weatherley-White et al., 1987; Mcheik et al., 2006). The subjects in this cohort who underwent delayed repair were

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